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PHCA

HIPAA Authorization to Release Medical Record Information

Pediatric Healthcare Associates

Altoona Office 615 6th Avenue, Altoona, PA 16602
Phone: (814) 944-7383 · Fax: (814) 944-7608
Roaring Spring Office 7664 Woodbury Pike, Roaring Spring, PA 16673
Phone: (814) 224-2555 · Fax: (814) 944-7608
PATIENT NAME
DATE OF BIRTH
MALE / FEMALE
I Authorize:
Name of practice/facility
Address
City, State, Zip
Phone
Fax
To Release To:
Name of practice/facility
Address
City, State, Zip
Phone
Fax
Indicate Why You Would Like These Records Released
Change of insurance Relocate / continuity of care Other:
Information to Be Released
All records Immunization record only Consultation Progress note
Diagnostic report Other:
Special Authorization
Alcohol and/or drug use record Psychiatric records Sexually transmitted disease
HIV/AIDS
Parent / Guardian Signature
Patient's Signature (18 and over)

I understand that this authorization shall be valid for one year. I understand that I may revoke this consent in writing to Pediatric Healthcare Associates at any time. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of the above-named patient on whether or not I sign this authorization.

Signature of Patient (18 or older)
Date
Signature of Parent/Guardian
Date
Patient/Parent/Guardian Phone Number

If there is a custody order on file you will need to provide us a copy.
A joint custody order requires signatures of all parties.

Pediatric Healthcare Associates · Altoona & Roaring Spring, PA · phcaaltoona.com HIPAA Record Release Form